That chart reflects the participants in Model 2 that are directly participating in the model — either as Awardees or as Episode Initiators. Although SNFs may furnish services to beneficiaries during a Model 2 episode, SNFs cannot participate as Awardees or as Episode Initiators in Model 2. SNFs are eligible to participate as Awardees or as Episode Initiators in Model 3.
We have proposed Medicare beneficiaries that initiate an episode in the Comprehensive Care for Joint Replacement model will retain their full rights to choose their providers. In order to decrease episode spending, hospitals included in this model will be incentivized to refer beneficiaries to highquality, low-cost providers. This proposed rule does not alter the existing responsibilities that hospitals have to share post-acute care provider information with beneficiaries when considering a post-acute care provider.
In order for a beneficiary to be included in an episode initiated in Comprehensive Care for Joint Replacement model, we have proposed that Medicare must be the primary payer. Where Medicare is the primary payer, and the beneficiary fulfills the other criteria for inclusion in the model described in section III.B.2.a of the Comprehensive Care for Joint Replacement model proposed rule, then the episode spending would include Medicare spending for all Part A and Part B services furnished to the beneficiary, except for the services that are specifically excluded in the rule.
We propose, in section III.B.2 of the proposed rule to exclude unrelated inpatient hospital admissions during the episode by identifying MS–DRGs for exclusion. We propose to exclude unrelated Part B services based on the ICD–9–CM diagnosis code (or their ICD–10–CM equivalents when ICD–10–CM codes are implemented) that is the principal diagnosis code reported on claims for services furnished during the episode. More specifically, we propose to exclude specific inpatient hospital admissions and services consistent with the lower extremity joint replacement (LEJR) episode definition (also triggered by MS–DRGs 469 and 470) that is currently used in BPCI Model 2.
Please see section III.C.10 of the proposed rule, which includes a detailed discussion of internal cost savings (ICS), including a requirement that ICS “must be transparent, measurable, and verifiable in accordance with Generally Accepted Accounting Principles (GAAP) and Government Auditing Standards (The Yellow Book),” as well as a requirement that the methodology included in any agreement between a participant hospital and another party must set out the specific care redesign elements to be undertaken by the participant hospital or the collaborator or both with regard to ICS.
We have proposed to use a total knee arthroplasty and/ or total hip arthroplasty (TKA/THA) patient-reported outcome measure that has been under development at CMS, as described in sections III.C.5(b)(2) and III.D.3 of the proposed rule.
Please see sections III.C.5(b)(2) and III.D.3 of the proposed rule, in which we discuss the use of a voluntary TKA/THA patient-reported outcome measure. We have proposed that a hospital that successfully meets the reporting threshold for this measure would have its discount reduced from 2 to 1.7.
Please see section III.C.10 of the proposed rule, in which we detail the types of financial arrangements that hospitals and certain providers (including physicians and physician group practices) might enter into in order to encourage financial alignment between various provider/ supplier types. For example, we have proposed that a hospital could share internal cost savings with certain provider/supplier types. Where a hospital experiences decreases in internal cost savings by instituting care redesign strategies or changes to the hospital’s processes (such as standardizing implant choices, for example), the hospital might choose to share those savings with providers/ suppliers that furnish services to beneficiaries during a Comprehensive Care for Joint Replacement episode, in order to incentivize compliance from those providers/ suppliers.
Jennifer Malin, MD, PhD, serves as a member of the Health Care Payment Learning & Action Network's Clinical Episode Payment Work Group. She is Staff Vice President for Clinical Strategy at Anthem, Inc., where she provides clinical leadership for the enterprise strategy to improve health outcomes of Anthem members, specifically within the specialties of oncology, maternity and infant health, and behavioral health.